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A Real Person will Answer 9:00 AM to 8:00 PM

Call Doug Ellsworth

503-922-2903

This is not the official website for HealthCare.Gov, but as a Certified Agent with FFM HealthCare.gov I can answer your questions.  Please visit http://www.healthcare.gov for complete information and coverage options.
Serving Clients in the following Counties and Cities.  This is not a complete list, as we help all clients in Oregon
Baker
Benton
Clackamas
Clatsop
Columbia
Coos
Crook
Curry
Deschutes
Douglas
Gilliam
Grant

Harney
Hood River
Jackson
Jefferson
Josephine
Klamath
Lake
Lane
Lincoln
Linn
Malheur
Marion

Morrow
Multnomah
Polk
Sherman
Tillamook
Umatilla
Union
Wallowa
Wasco
Washington
Wheeler
Yamhill

Cities by Counties

Baker County

Baker City
Greenhorn
Haines
Halfway
Huntington
Richland
Sumpter
Unity

Benton County

Adair Village
Albany
Corvallis
Monroe
Philomath

Clackamas CountyBarlow
Canby
Damascus
Estacada
Gladstone
Happy Valley
Johnson City
Lake Oswego
Milwaukie
Molalla
Oregon City
Portland
Rivergrove
Sandy
Tualatin
West Linn
Wilsonville 

Clatsop County

Astoria
Cannon Beach
Gearhart
Seaside
Warrenton

Columbia CountyClatskanie
Columbia City

Prescott
Rainier
Scappoose
St. Helens
Vernonia 

Coos County

Bandon
Coos Bay
Coquille
Lakeside
Myrtle Point
North Bend
Powers 

Crook County

Prineville

Curry County

Brookings
Gold Beach
Port Orford 

Deschutes County

Bend
La Pine
Redmond
Sisters

Douglas County

Canyonville
Drain
Elkton
Glendale
Myrtle Creek
Oakland
Reedsport
Riddle
Roseburg
Sutherlin
Winston
Yoncalla

Gilliam County

Arlington
Condon
Lonerock 

Grant County

Canyon City
Dayville
Granite
John Day
Long Creek
Monument
Mt. Vernon
Prairie City
Seneca 

Harney County

Burns
Hines

Hood River County

Cascade Locks
Hood River

Jackson County

Ashland
Butte Falls
Central Point
Eagle Point
Gold Hill
Jacksonville
Medford
Phoenix
Rogue River
Shady Cove
Talent

Jefferson County

Culver
Madras
Metolius

Josephine County

Cave Junction
Grants Pass

Klamath County

Bonanza
Chiloquin
Klamath Falls
Malin
Merrill

Lake County

Lakeview
Paisley

Lane County

Coburg
Cottage Grove
Creswell
Dunes City
Eugene
Florence
Junction City
Lowell
Oakridge
Springfield
Veneta
Westfir

Lincoln County

Depoe Bay
Lincoln City
Newport
Siletz
Toledo
Waldport
Yachats 

Linn County

Albany
Brownsville
Halsey
Harrisburg
Idanha
Lebanon
Lyons
Mill City
Millersburg
Scio
Sodaville
Sweet Home
Tangent
Waterloo 

Malheur County

Adrian
Jordan Valley
Nyssa
Ontario
Vale

Marion County

Aumsville
Aurora
Detroit
Donald
Gates
Gervais
Hubbard
Idanha
Jefferson
Keizer
Mill City
Mt. Angel
Salem
Scotts Mills
Silverton
St. Paul
Stayton
Sublimity
Turner
Woodburn

Morrow County

Boardman
Heppner
Ione
Irrigon
Lexington

Multnomah County

Fairview
Gresham
Maywood Park
Portland
Troutdale
Wood Village 

Polk County

Dallas
Falls City
Independence
Monmouth
Salem
Willamina

Sherman County

Grass Valley
Moro
Rufus
Wasco

Tillamook County

Bay City
Garibaldi
Manzanita
Nehalem
Rockaway Beach
Tillamook
Wheeler 

Umatilla County

Adams
Athena
Echo
Helix
Hermiston
Milton-Freewater
Pendleton
Pilot Rock
Stanfield
Ukiah
Umatilla
Weston

Union County

Cove
Elgin
Imbler
Island City
La Grande
North Powder
Summerville
Union 

Wallowa County

Enterprise
Joseph
Lostine
Wallowa 

Wasco County

Antelope
Dufur
Maupin
Mosier
Shaniko
The Dalles

Washington County

Banks
Beaverton
Cornelius
Durham
Forest Grove
Gaston
Hillsboro
King City
North Plains
Portland
Rivergrove
Sherwood
Tigard
Tualatin 
Wilsonville 

Wheeler County

Fossil
Mitchell
Spray

Yamhill County

Amity
Carlton
Dayton
Dundee
Lafayette
McMinnville
Newberg
Sheridan
Willamina
Yamhill

 

 

 

 

 


HealthCare.Gov

1-800-318-2596
OHP/Medicaid
1-800-699-9075
Providence Health Plans
Member Services
800-878-4445
Customer Service
503-574-7500
Moda Health Plans
503-243-3973

Kaiser Permanente
503-813-2000
Oregon CO-OP
844-509-4676
BridgeSpan Health
855-857-9943
LifeWise Health Plans
800-596-3440
Pacific Health Plans
888-977-9299
 
 
 

Breaking News







 

 

Oregon ACA.com

Health Benefits Solution, Inc


 

 

 

 

"A Real Person Will Answer"

Call 503-922-2903

5200 SW Meadows Rd, Suite 150

Lake Oswego OR 97035

Email: Doug@OregonACA.com

Fax: 503-908-7897

Doug Ellsworth, NPR Certified Agent #7139388

Nancy Taylor, NPR Certified Agent # 7435825

 

 

Open Enrollment Starts November 1st, 2016 through January 31st, 2016


Apply Now For Health Coverage 2016

 

Health Insurance Companies 2016 Plans

 

STM Short Term Medical "LifeMap"

STM Short Term Medical "HCC"

IMG International Travel Insurance

IMG Coverage Brochure

HCC International Travel


2016 Open Enrollment Extended to December 17th, for January 1st Effective Date

Alert: CMS Extends Deadline to Enroll in FFM Coverage with January 1st Effective Date

Today, the Centers for Medicare & Medicaid Services (CMS) announced the deadline for January 1, 2016, health insurance coverage on the Federally-facilitated Marketplace (FFM) has been extended until December 17, 2015, at 11:59 p.m. PST. The announcement can be found on Healthcare.gov.

The CMS Center for Consumer Information and Insurance Oversight (CCIIO) Marketplace CEO Kevin Counihan stated that, “Because of the unprecedented demand and volume of consumers contacting our call center or visiting Healthcare.gov, we are extending the deadline to sign up for January 1 coverage until 11:59 p.m. PST, December 17. Hundreds of thousands have already selected plans over the last two days and approximately one million consumers have left their contact information to hold their place in line. Our goal is to provide access to affordable coverage, and the additional 48 hours will give consumers an opportunity to come back and complete their enrollment for January 1 coverage.”

 

Please Read, From Doug Ellsworth NPR# 7139388, Health Benefits Solution, Inc.

Open enrollment is almost here starting Saturday, November 1st, 2015.  I will be available to help with questions and suggestions, and remember my services as your agent do not cost you anything, free service to you and your family.

I will be using a special dashboard that will streamline the enrollment process and should only take 5 to 10 minutes total, and will automatically include me as your agent.   My special link will not work until November 1st, so please do not access it until then.  You can currently preview plans and rates through HealthCare.gov, and you will see any Tax Credit available to you including any plan modification associated. 

Keeping you listed as my client, and me as your agent is not always easy, especially if you try to enroll through HealthCare.gov on your own.  If you do try to enroll on your own without my assistance, please list me as your agent in the process, again there is no additional charge, but this will allow me to help in the future with questions on billing and claims.  During the Application Process, HealthCare.gov will ask “Do you have someone helping you with this application?”  YOU NEED TO SAY YES, and then list Douglas Ellsworth, NPR Agent Number 7139388, Health Benefits Solution, Inc.  My address and contact information is listed at the end of this email.

To browse all plans available in your zip code, click this link and answer a few basic questions to see the plans.  Once you see a plan that will work for you, “click” on the plan to access additional information, including “Provider Look Up”, this is a very important step as not all doctors and facilities work will all the plans.

http://www.healthcare.gov

Be sure to write down the plan name, price and plan ID number, so I can help streamline the enrollment process.

Starting November 1st, 2015 use this link to access my enrollment dashboard to complete the process.

https://oregonaca.acaexpress.com/?npn=7139388#/

Complete the field for “Finding a Plan”.  You will be asked for additional information including family members and 2016 estimated Adjusted Gross Income.  VERY IMPORTANT, if you have any deductions that lower your taxable income, you need to subtract them from the income you list for yourself.  There are no fields to list deductions, so you need to adjust your income to show the correct amount of your estimated taxable income for 2016.

The first week of Open Enrollment is going to be very busy for me, but keep in mind I will be available to help you, and want to answer any and all questions you have.  The best way to reach me is through email with you question, I can then answer via email or call you back if that is your request.

Hoping all computer systems work as promised this year, to make your enrollment process simple and easy.

2015 health insurance plans and prices

Browse Plans and Tax Credits if available

Help Me Set Up Obama Care Health Insurance in Oregon

Starting November 1st, 2015 I will have access to help enroll clients through the  HealthCare.Gov Portal.  As a Certified Agent I can answer questions, and show you the plan options and rates which will go effective January 1st, 2016.  If you would like my help just click the above link and I will give you a call and answer questions you have.  My time and services are free and I am available 9:00 am to 8:00 pm 7 days a week.

Between Jobs, or Unemployed!  Offered Cobra Health Insurance and cannot afford the premiums?  The are many Low Cost, and Affordable options.  All coverage is with Major Health Insurance Companies and a "Real Person" will answer the phone to help you!

The focus of this website is to provide consumers a simple, and professional environment when looking for Affordable, and Low Cost Health Insurance.  Licensed Health Insurance Agents are available and will take the time to answer all your questions, and help find the Health Plan that best meets your needs

Health Insurance Benefits are always changing, and health insurance companies are providing more options that benefit the consumer.  Alternative, or Holistic health care is now offered through many of the health insurance companies.  You can now see your Naturopathic Physician, and be covered under the doctor office co-pay, and have unlimited visits.  Chiropractic, and Acupuncture are also included as standard health care benefits with many companies.

If you are looking for Low Cost and Affordable Dental and Vision benefits included within the health plan, we can help you select the Health Insurance Company that will meet your needs.

Health Benefit Solution, Inc is licensed through the Oregon Insurance Division, and has contracted with most all the major health insurance companies to provide the consumer with choice and options when looking for the plan that meets the life style and needs of the insured.

Health Benefits Solution, Inc is a leader in offering Company Direct Health insurance coverage for all individuals, and small business in Oregon.  The Affordable Care Act and HealthCare.gov will offer affordable health insurance options to all Oregonians with or without tax credits or CSR "Cost Sharing Reductions".  The Oregon Health Plan will still be offered through CoverOregon.com


 

Important dates for 2016 enrollment:

  • November 1, 2015: Open Enrollment starts — first day you can enroll in a 2016 Marketplace plan. Coverage can start as soon as January 1, 2016.

FYI2016 plans and prices will be available for preview the third week of October, 2015.

  • December 15, 2015: Last day to enroll in or change plans for new coverage to start January 1, 2016.
  • January 1, 2016: 2016 coverage starts for those who enroll or change plans by December 15.
  • January 15, 2016: Last day to enroll in or change plans for new coverage to start February 1, 2016
  • January 31, 2016: 2016 Open Enrollment ends. Enrollments or changes between January 16 and January 31 take effect March 1, 2016.

If you don’t enroll in a 2016 plan by January 31, 2016, you can’t enroll in a health insurance plan for 2016 unless you qualify for a Special Enrollment Period.

Medicaid, CHIP, and SHOP – apply any time

The fee if you don’t have coverage in 2016

If you don’t have coverage in 2016, you may have to pay a fee. The fee is higher in 2016 than it was in 2015. Learn about the fee for not having health coverage in 2016.

 

 

How can I get health coverage outside the yearly Open Enrollment?

It depends on what coverage you qualify for.

  • A health insurance plan. Outside Open Enrollment, you can enroll only if you qualify for a Special Enrollment Period (SEP). You qualify if you have a baby, get married, lose job-based coverage, or have certain other life changes. See all changes that qualify for SEPs.
  • Medicaid and the Children’s Health Insurance Program (CHIP). You can apply for these free or low-cost programs any time of year. If you qualify, you can enroll immediately.

Answer a few questions and we’ll tell you if you may qualify for a Special Enrollment Period or Medicaid/CHIP.

If you don’t qualify for either one, you can apply as soon as November 1 for coverage starting January 1, 2016.

As of Jan. 1, 2014, the Affordable Care Act requires that most Americans buy health insurance or face a tax penalty. Those who purchase health insurance coverage through the state-based and federally facilitated exchanges that make up the Health Insurance Marketplace may be eligible for tax credits that help lower monthly premiums.

Premium tax credits are available only to those who are not eligible for affordable coverage from other sources and whose incomes fall within two to four times the federal poverty level. During 2015 open enrollment, 87 percent of those who purchased health insurance coverage through HealthCare.gov chose plans with financial assistance.1
 
Health Care Reform Calculator to estimate your annual health insurance premium and tax credit. Note: This credit is only available when you purchase health insurance coverage from a state-based or federally facilitated exchange.

The individual shared responsibility payment

Those who go without health insurance and do not qualify for an exemption may owe a penalty known as the shared responsibility payment when filing their federal income taxes.

If you go without coverage in 2015, the individual shared responsibility payment is the greater of2:

  • 2 percent of your household income that is above the tax return threshold for your filing status, such as married filing jointly or single, or
  • Your family’s flat dollar amount, which is $325 per adult and $162.50 per child under 18, with a maximum penalty per family being $975.

The penalty is capped at the cost of the national average premium for a bronze level health insurance plan purchased through the state-based and federally facilitated exchanges.3

In 2016, this penalty will increase as follows:

  • 2.5 percent of your household income that is above the tax return threshold for your filing status, or
  • Your family’s flat dollar amount, which is $695 per adult and $347.50 per child under 18.

Each year after 2016, the shared responsibility payment will increase with inflation. Exemptions apply to certain populations, such as those with brief coverage gaps, those who cannot afford coverage, members of federally recognized Indian tribes and members of recognized religious groups that object to certain benefits.

Calculation tools

With the arrival of 2014 and the first Obamacare open enrollment, many tax credit calculators appeared. These online tools can help you understand the Affordable Care Act from a personalized, dollars-and-cents perspective.

Health Care Reform Calculator helps individuals and families determine how the requirement to buy health insurance coverage will specifically impact them. Simply enter your age, state, income and any additional family members’ ages to determine what you can expect to pay for a Bronze, Silver, Gold or Platinum plan through the exchanges. The cost with and without the tax credit is calculated. You can also learn what your opt-out penalty will be should you choose to go without qualified health insurance coverage. Small business owners who offer health insurance to their employees may also use this calculator to determine costs.

Tax credit options

When you enroll in a state-based or federally facilitated health insurance plan with financial assistance, you will have two options4:

  1. Get it now – Elect to have the health insurance company apply all or some of the estimated tax credit to your monthly premium.
  2. Get it later – Claim the tax credit when you file your federal income tax return.

It is important to note that if your income or family size changes throughout the year, it may impact your premium tax credit. Be sure to report such changes to your state’s health insurance exchange so they may adjust your premium amount accordingly. Failing to do so may result in you owing money when filing your taxes, if your income increased or family size decreased. If your income decreases or family size increases and you fail to report it, you may receive a refund.

 

Most health plans must cover a set of preventive services like shots and screening tests at no cost to you. This includes Marketplace private insurance plans.

Free preventive services

All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

This applies only when these services are delivered by a network provider.

  1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  2. Alcohol Misuse screening and counseling
  3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
  4. Blood Pressure screening for all adults
  5. Cholesterol screening for adults of certain ages or at higher risk
  6. Colorectal Cancer screening for adults over 50
  7. Depression screening for adults
  8. Diabetes (Type 2) screening for adults with high blood pressure
  9. Diet counseling for adults at higher risk for chronic disease
  10. HIV screening for everyone ages 15 to 65, and other ages at increased risk
  11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:

  12. Obesity screening and counseling for all adults

  13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  14. Syphilis screening for all adults at higher risk
  15. Tobacco Use screening for all adults and cessation interventions for tobacco users

 

List of Ten Essential Health Benefits
  1. Ambulatory patient services (Outpatient care). Care you receive without being admitted to a hospital, such as at a doctor’s office, clinic or same-day (“outpatient”) surgery center. Also included in this category are home health services and hospice care (note: some plans may limit coverage to no more than 45 days).
     
  2. Emergency Services (Trips to the emergency room). Care you receive for conditions that could lead to serious disability or death if not immediately treated, such as accidents or sudden illness. Typically, this is a trip to the emergency room, and includes transport by ambulance. You cannot be penalized for going out-of-network or for not having prior authorization.
     
  3. Hospitalization (Treatment in the hospital for inpatient care). Care you receive as a hospital patient, including care from doctors, nurses and other hospital staff, laboratory and other tests, medications you receive during your hospital stay, and room and board. Hospitalization coverage also includes surgeries, transplants and care received in a skilled nursing facility, such as a nursing home that specializes in the care of the elderly (note: some plans may limit skilled nursing facility coverage to no more than 45 days).
     
  4. Maternity and newborn care. Care that women receive during pregnancy (prenatal care), throughout labor, delivery and post-delivery, and care for newborn babies.
     
  5. Mental health services and addiction treatment. Inpatient and outpatient care provided to evaluate, diagnose and treat a mental health condition or substance abuse disorder . This includes behavioral health treatment, counseling, and psychotherapy. (note: some plans may limit coverage to 20 days each year. Limits must comply with state or federal parity laws.
     
  6. Prescription drugs. Medications that are prescribed by a doctor to treat an illness or condition. Examples include prescription antibiotics to treat an infection or medication used to treat an ongoing condition, such as high cholesterol. At least one prescription drug must be covered for each category and classification of federally approved drugs, however limitations do apply. Some prescription drugs can be excluded. "Over the counter" drugs are usually not covered even if a doctor writes you a prescription for them. Insurers may limit drugs they will cover, covering only generic versions of drugs where generics are available. Some medicines are excluded where a cheaper equally effective medicine is available, or the insurer may impose "Step" requirements (expensive drugs can only be prescribed if doctor has tried a cheaper alternative and found that it was not effective). Some expensive drugs will need special approval.
     
  7. Rehabilitative services and devices – Rehabilitative services (help recovering skills, like speech therapy after a stroke) and habilitative services (help developing skills, like speech therapy for children) and devices to help you gain or recover mental and physical skills lost to injury, disability or a chronic condition (this also includes devices needed for "habilitative reasons"). Plans have to provide 30 visits each year for either physical or occupational therapy, or visits to the chiropractor. Plans must also cover 30 visits for speech therapy as well as 30 visits for cardiac or pulmonary rehab.
     
  8. Laboratory services. Testing provided to help a doctor diagnose an injury, illness or condition, or to monitor the effectiveness of a particular treatment. Some preventive screenings, such as breast cancer screenings and prostrate exams, are provided free of charge.
     
  9. Preventive services, wellness services, and chronic disease treatment. This includes counseling, preventive care, such as physicals, immunizations and screenings, like cancer screenings, designed to prevent or detect certain medical conditions. Also, care for chronic conditions, such as asthma and diabetes. (note: please see our full list of Preventive services for details on which services are covered.)
     
  10. Pediatric services. Care provided to infants and children, including well-child visits and recommended vaccines and immunizations. Dental and vision care must be offered to children younger than 19. This includes two routine dental exams, an eye exam and corrective lenses each year.

While all qualified plans must offer the ten essential benefits, the scope and quantity of services offered under each category can vary. Each qualified plan must offer essential health benefits which overall are equal to the scope of benefits typically covered by employers, as shown by a Department of Labor survey of employer-sponsored coverage. (Ref: ACA, Section 1302 (b) (2) (a))

Read SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS of the Affordable Care Act for yourself. You can also check out the official rules for Essential Health Benefits which defines how included benefits will work as this was not included in the law itself.

 

When Do Essential Health Benefits Start?

 

 

Under the Affordable Care Act Essential Benefits are offered on all qualifying plans starting January 1st, 2014.

Who Has Access to Essential Health Benefits?

All plans sold in individual and small group markets, including plans sold on and off the Health Insurance Marketplace, and Government healthcare plans like Medicaid and Medicare all include at least 10 Essential Benefits. Grandfathered plans from before the law was enacted in March 23, 2010, plans that will be discontinued in 2015 (2014 in some States), self-funded ASO (administrative services organization) plans, and large group plans don't have to offer Essential Benefits.

• In older plans, not offering these benefits can translate to lower premium costs (because they offer less benefits)

• Large group plans almost all already offer essential health benefits or their equivalent.

• All new Medicaid and Medicare plans must offer essential health benefits starting in 2014.

• Specific health care benefits may vary by state. Even within the same state, there can be small differences between health insurance plans

What Do Essential Benefits Cost?

Some Essential Benefits include no out-of-pocket costs (no cost sharing) and all Essential Benefits offer no annual or lifetime limits and have minimum cost sharing limits.

No Cost Sharing on Some Preventive Services

Essential Health Benefits include annual wellness visits and many types of preventive services including immunizations and screenings at no out of pocket costs. The Affordable Care Act has a major focus on wellness and prevention to help increase early detection and catch sickness before it starts increasing wellness and decreasing the need for costly treatments. (note: For preventive care to have no out-of-pocket expense it must be  delivered by a network provider.)

No Annual Limits on Essential Health Benefits

There are no dollar limits on Essential Benefits. Before annual and lifetime limits over 60% of bankruptcies in the US were medical bankruptcies. Eliminating dollar limits on essential care ensures that patients won't have to stop treatment and/or go broke when they reach their dollar limit.

A Minimum Actuarial Value on All Coverage

There is a cap on out-of-pocket costs on all plans that cover Essential Benefits. Plans offering Essential Benefits must cover at least 60% of covered out-of-pocket expenses and must have reasonable out-of-pocket maximums (in other words a plan offering essential benefits must be at least the equivalent to a "bronze" plan sold on the marketplace.)

Plans must provide one of four levels of benefits, named "Bronze", "Silver", "Gold" and Platinum. Each designation represents an "actuarial value", which is calculated as the average % of total health costs they cover for a defined population). Bronze plans cover 60% on average, "Silver" 70%, "Gold" 80% and "Platinum" 90% of costs on average. For most individuals though a plan will pay far less than these percentages: this is because a high proportion of health care costs are incurred by a small number of very sick people, and once they reach the out-of-pocket maximums, the plan pays 100% of their extra costs.

In general, the higher the metallic level (i.e. Gold and Platinum), the more the plan will pay towards your healthcare expenses, but the higher your monthly premiums will be. Higher tier plans may also offer additional benefits that are not considered "essential".

Out-of-pocket Maximum (Limit)

Your out-of-pocket maximum (limit) is the most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges, or health care your health insurance or plan doesn’t cover. All cost sharing for Essential Benefits counts towards your out-of-pocket limit.

Please note that some plans don’t count your copayments, deductibles, coinsurance payments, out-of-network payments, or other expenses toward this limit. In Medicaid and CHIP, the limit includes premiums. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.

Why Do I Need Essential Health Benefits?

In the past many plans offered sub-par coverage as a way to keep premium costs down. This would seem attractive until one actually needed care. This led to many cases of Americans paying for plans for years and then finding that they did not have access to the care they needed or hit a dollar limit and were denied treatment when they needed it most. Today all plans cover essential health benefits to ensure that we all get the care we need.

Why Do I Have to Pay For Benefits I Don't Need?

While most Essential benefits could be used by anyone, many benefits like Maternity services are included on all plans. One could argue a single male, who never has children, won't benefit from this directly (although it's easy to argue countless ways he benefits indirectly notably his mother, sisters, relatives, community, etc), leading to the obvious question, "why do I have to pay for something I don't need?"

In employment based group health insurance policies, all employees of a company pay the same premium, regardless of their individual health needs. So the premium younger workers pay helps subsidize the higher health costs of older employees. Although this means higher premiums for young employees, when employees get older they will benefit from this arrangement. Similarly male workers will pay premiums that include costs of maternity care and breast cancer, even though they are unlikely to need either. In insurance terms, all members of the group are considered as a "risk pool".

The Affordable Care Act creates a "single risk pool" in the individual and small group markets that mirrors the "risk pools" employees of large firms have enjoyed in the past. This means that regardless of what care you need, or may need, we all share the cost and the risk. This allows insurance companies to cover men at the same rate as women and sick people at the same rate as healthy people. Without a single risk pool insurance would still be unaffordable for many and preexisting conditions would not be covered. Since there is a single risk pool that splits the costs of Essential Benefits all Essential Benefits are offered to all insured.

How Do I Know if My Plan Covers Essential Health Benefits?

If you enrolled in an individual or small group plan after 2014 you most likely have access to Essential Health Benefits that follow the rules of the ACA. The same is true for Medicare and Medicaid.

The ACA contains exceptions for "grandfathered" plans, . These are plans that existed prior to the Act - March 23, 2010, provided that they have not changed significantly. Unfortunately most insurance plans change "significantly" almost every year, so few plans are "grandfathered".There are also special exceptions for self-insured groups, and student health plans. In addition both large employer group plans, and now individual plans, have been allowed to continue until 2015 unchanged.

Exceptions and Limits on Essential Health Benefits

There are some exceptions and limits on Essential Benefits, they are:

• Insurance companies can still put a yearly dollar limit and a lifetime dollar limit on spending for health care services that are not considered essential health benefits.

• Some health insurance plans may have received a temporary waiver from the rules on yearly dollar limits. Yearly limit waivers end with plan or policy years beginning in 2015 (2014 in some States).

• All non-grandfathered health plan must limit the total out-of-pocket costs enrollees pay for in-network.

• Health plans can still however set limits on the number of times you can receive a certain treatment.

• Large Group markets and self funded (ASOs) don't need to offer Essential Benefits.

Essential Benefits Facts

Here are some quick facts about Essential Health Benefits and the Affordable Care Act (ObamaCare):

• Cost sharing on Essential Health Benefits count towards your maximums.

• Aside from the Essential Health Benefits, plans may offer a number of additional benefits.

• Some plans may offer better cost sharing options on benefits subject to out-of-pocket cost sharing. In general the more "valuable" the metal, the higher the percentage of out-of-pocket costs covered by your insurer.

• Essential Health Benefits include the most commonly used health services like preventive services and annual wellness visits with no cost sharing.

• Essential Health Benefits include preventions and treatments you need if you get sick. This includes ongoing treatment for common serious sicknesses like cancer.

• There are no annual or lifetime limits on Essential Health Benefits. Before the ACA over 60% of all bankruptcies in the US were medical related, many due to the cost of treatment exceeding annual and lifetime dollar limits.

• The annual cost to society of substance use disorders alone is approximately $200 billion, yet only a fraction ($15 billion) is spent on treatment. The inclusion of mental health and substance use disorders services is projected to balance these numbers and reduce healthcare costs.

• Instead Essential Benefits, large employers only have to offer "Minimum Essential Coverage" without the act really defining what this is. This has caused some companies to adopt "skinny plans" with very limited coverage. There are no limits on out-of-pocket cost for services not covered! See http://www.kaiserhealthnews.org/Stories/2013/August/26/essential-benefits-bare-bones-health-insurance.aspx

Essential Benefits Myths

Here are some common myths about Essential Health Benefits and the Affordable Care Act (ObamaCare):

 There are no dollar limits on healthcare. Dollar limits still apply to non-essential treatments, essential benefits are covered at no dollar limits and must have reasonable out-of-pocket maximums.

 All Essential Benefits are "free". Only some preventive services have no out-of-pocket expenses. Other benefits may have reduced, or no, out-of-pocket expenses depending on the plan. Even a "free" service still comes with the cost of your monthly premium. See a list of all required "free" Preventive services.

• Abortions have to be provided on demand at public cost. False! The ACA Sect 1303 explicitly prohibits abortion from coverage as an "essential benefit" and confirms existing Federal and State prohibitions on use of public funds for abortion services. Insurers may voluntarily decide to include abortions in their plans: some plans only cover abortion services only in cases of life endangerment, rape, and incest. States who are providing their own health insurance marketplaces, prohibit coverage of abortion services. So far Arizona, Louisiana, Mississippi, Missouri, and Tennessee have banned coverage of abortions. The bans in Louisiana and Tennessee do not contain any exceptions. Missouri only allows coverage where a woman’s life is endangered, Arizona has a life and narrow health exception,and Mississippi allows coverage where a woman’s life is endangered or the pregnancy is the result of rape or incest. In addition – Idaho, Oklahoma, Kentucky, Missouri and North Dakota already ban health insurance companies from covering abortion except by optional rider. If an insurer offers abortion in cases other than life endangerment, rape or incest, then it must separate the cost of such coverage and charge a separate premium for such coverage. Seehttp://www.dpc.senate.gov/healthreformbill/healthbill18.pdf

 Paying for care I don't need means higher premiums. This isn't a myth as much as a misunderstanding of how the law works. In order to make insurance affordable for all Americans a "single risk pool" is created. Since the risk is shared by all insurers, premium prices reflect not only the risk, but all benefits, rights, and protections offered by the Affordable care Act. The only way to provide affordable health insurance for the sick, is for the healthy to share the cost: after all you might become sick and need that help tomorrow, or next year, or in ten years time. This is the way employer group plans work. However, unlike employer group plans, marketplace plans for individuals allow a lower premiums for younger members, while limiting the maximum premium paid by the elderly to three times the premium for a young person. The only way to offer specific care to specific people for specific prices, would be to eliminate the ban on imposing annual and lifetime limits, the ban on gender and health discrimination, and the ban on denying coverage and treatment to people with preexisting conditions. As it stands now many people will pay less than they did before the law due to the aforementioned bans and subsidies, while many will pay more due to the way the new system works. Regardless all Americans buying new plans will have better benefits, rights, and protections on equivalent plans.

 

 

Unofficial Resources on Essential Health Benefits:http://www.forbes.com/sites/investopedia/2013/10/11/essential-health-benefits-under-the-affordable-care-act/ - https://www.healthcare.gov/blog/10-health-care-benefits-covered-in-the-health-insurance-marketplace/ - http://lpfch-cshcn.org/publications/issue-briefs/habilitative-services-coverage-for-children-under-the-essential-health-benefit-provisions-of-the-affordable-care-act/